As the population ages, a growing number of hospitalized older adults will require the assistance of family members and other surrogates to make medical decisions for them. There is evidence that communication between clinicians and surrogates is often poor, that surrogate decision makers experience high degrees of distress during and after hospitalization, and that patients sometimes receive care that is ineffective or unwanted. Our research group has proposed that the quality of communication between clinicians and surrogates improves both the quality of decision making and outcomes for both patients and their surrogates. However, we do not know which elements of communication are most important to the surrogates and should therefore be the focus of future intervention and we have a limited understanding of the mechanisms by which communication impacts outcomes for patients and surrogates. To gain a better understanding of these issues, we need a high quality instrument to assess surrogate/clinician communication and decision making in the hospital setting. To our knowledge, there is no well-validated instrument for this purpose. The current R01 proposal will validate a new instrument to measure the quality of communication between surrogate decision makers and clinicians in the hospital setting and will examine relationships between this measure and decision quality, surrogate distress and patient outcomes. This new measure, the Family Inpatient Communication Survey, examines several elements of communication that we have identified in our earlier work to be especially important for decision making, such as emotional support and frequent communication. We have drafted the instrument, conducted expert review and pilot tested it. The proposed R01 study will conduct the essential next step, validating the instrument with surrogate decision makers from 3 diverse hospitals in the Indianapolis area, including an urban public hospital, a tertiary referral center, and a suburban community hospital. We will also administer other well-validated measures of decision quality, surrogate outcomes (such as distress and depression), and patient care outcomes and will examine the relationships between communication quality, decision making quality, and patient and surrogate outcomes. We have assembled a diverse group of investigators with expertise in geriatrics, ethics, nursing and psychometrics. The research team will be advised by a Clinician Advisory Panel, including ICU physicians, a social worker and a nurse, to advise on the implementation of the study in the clinical setting. Findings from the current research will be crucial in the development of an intervention to improve communication and decision making in the hospital. The long term goal of this research agenda is to improve the quality of decisions for hospitalized patients and to improve the distress of surrogates who must make difficult choices for patients.